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F0600
D

Failure to Protect Residents from Physical Abuse by Peers

Santa Rosa, California Survey Completed on 12-22-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from physical abuse by other residents in two separate incidents. In the first incident, a resident with schizophrenia and no memory impairment struck another resident, also with schizophrenia and no memory impairment, several times on the back of the head while the latter was sitting on his bed. The assaulted resident reported the incident, denied pain, and had no visible injuries. The aggressor admitted to hitting the other resident, stating that the victim was making weird noises. Facility staff, including the case manager and program director, confirmed the occurrence of physical abuse. In the second incident, a resident diagnosed with schizoaffective disorder hit another resident, who also had schizophrenia and no memory impairment, several times in the head while she was lying in bed. The victim experienced mild pain to the right temple and expressed fear of the aggressor. The program director documented the incident and acknowledged it as physical abuse. Both incidents were confirmed through interviews and record reviews, and the facility's policy states that residents have the right to be free from abuse, including physical abuse.

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